Long story short, it was suggested to me that I administer sublingual morphine to a sleeping patient. I see several problems with this.
1. In my view, this takes away the patients right to know what medication they're receiving and also their right to refuse.
2. All I can see is aspiration pneumonia on the horizon.
3. Is that even flipping ethical?
I will not do this. Absolutely not. Not when the patient is alert and with it enough to ask what medications they are taking. My morals don't allow this.
So, what route do I take if I catch flack from management? And I'd love to hear your thoughts on this.
I do see your concerns and understand why it would seem unethical. There is much more to be considered, like the other posters indicated.
Your goal is not to keep someone "knocked out" or compromise their respiratory status by giving them SL morphine when they're already asleep. The goal would be to manage symptoms using medications prescribed per orders, using your nursing process/critical thinking/feedback loop to help keep things on track.
Sometimes that management includes atc dosing to control pain/dypsnea - no different, really, than continuous dosing through PCA pump or similar...FWIW, the amount of SL morphine is usually tiny - a 5mg dose being 0.25mL, or 1/20th of a teaspoon.
First off, just because a patient is sleeping does not mean they are not having pain. Some cope with their pain by using sleep as a diversional tool. Yes pain medication that is prn should be asked for but not everyone will ask but you should clarify how the patient was they prn medication handled. Another thing is sometimes it is best to give the medication when they can have it to prevent the pain or respiratory distress. This patient also sounds like on the SL morphine to keep comfortable and if he is not getting it through the night the day nurses are most likely playing catch up. Another thing...you should ask the patient at the beginning of the shift during initial assessment if the medication is want through the night. There are also ways to assess patients for pain if the patient is not able to verbally talk to you. For example they are on hospice in their final hours will you with hold medications if the patient has facial grimacing, tense muscles and restless who looks to be sleeping?
There are times where I've given morphine SL PRN to a sleeping patient who did not request it and I don't regret it. PRN is up to my discretion too and I decided that they needed it for whatever reason and gave it to them.
If other nurses are telling you to give a resident something PRN when they are sleeping, ask why. Perhaps the resident is complaining or showing signs of pain every morning at 0800 or something. Or perhaps the resident said "I wake up all the time at 0200 with pain but I feel bad disturbing the staff."
If the person is hospice it's important, at least to me, to control pain or potential pain - so to me that would mean giving it even if they don't necessarily have pain. But if the person is on it for something else,
I think it's okay to wake them and ask if they are needing pain medicine.
Based on what we know, I'm not seeing the nata for the prn dose overnight. The patient sleeps soundly without s/sx dyspnea; the med is given routinely during the day but not at night, and the pt had stated they would ask for the med at night if it were needed. There'd be nothing to chart as a reason for giving the PRN dose, no positive outcome to document afterward. PRN is PRN, and it's up to the nurse taking care of the patient at the time to evaluate the need and be accountable for the dosing.
Sometimes, when it comes to others' "suggestions" the best approach is "smile and wave, boys...just smile and wave..."
The patient is on Hospice. The day shift should talk to the Hospice nurse and the family about their wishes and get the Morphine scheduled in addition to having PRN available. Most Hospice patients have the goal of comfort for their end of life care. I have had many patients on Hospice and have not hesitated to get scheduled orders to meet the patient needs and wishes if necessary. Dying is painful and cannot always be voiced and the slightest grimace can be missed.
The patient is on Hospice. The day shift should talk to the Hospice nurse and the family about their wishes and get the Morphine scheduled in addition to having PRN available. Most Hospice patients have the goal of comfort for their end of life care. I have had many patients on Hospice and have not hesitated to get scheduled orders to meet the patient needs and wishes if necessary. Dying is painful and cannot always be voiced and the slightest grimace can be missed.
Just to update...I went in the next night after posting this and the patient was dyspnic, resps were very labored. I did wake her up and explain that I was going to give her morphine to help slow her respirations so she could relax a little more and she was grateful.
The following night, her respirations were even, unlabored, and she was sleeping very peacefully...according to her aid, she didn't wake at all that night. So I did not administer the morphine.
As far as pain issues, the only time she is having pain is when she is up and walking around. At rest, per the pt, she has no pain. Morphine at night is explicitly for dyspnea.
And I haven't heard days complain about any issues with her...if she was having dyspnea first thing in the morning, believe me, I'd hear about it.
jojo489
256 Posts
That's the plan. I just have to catch the pt while they're awake.